Tinnitus week 2021 is well underway. A great time to highlight the complexity of tinnitus, how the Coronavirus pandemic has affected tinnitus sufferers worldwide and a chance to look at where we are with current research.
An interesting collaboration between The British Tinnitus Association and Dr Eldre Beukes, a postdoctoral researcher and clinical scientist in Audiology at Anglia Ruskin University in Cambridge, has found that 46% of UK sufferers of tinnitus report that their tinnitus has been made worse due to the impact of lockdown and subsequent lifestyle changes. Over the last 4 months, in my own clinic, 30% of all patients seen have reported hearing tinnitus sounds, many who have never experienced it before. The research involved 48 countries with 3103 participants. It was found that people living with tinnitus in the UK were most likely to report how the pandemic had negatively affected their tinnitus, compared to those in the other countries involved in the research. Interestingly women and adults under the age of 50, were more likely to report that their tinnitus had worsened since the pandemic began. For those people who had had Covid-19 symptoms, 40% reported that their tinnitus had worsened. We are all aware of the restrictions imposed on our society to help to reduce the spread of the virus and the results do seem to show that one such consequence can be increasing tinnitus.
So let's remind ourselves of what tinnitus actually is. The National Institute for Health and Care Excellence define tinnitus as the perception of sound in the absence of sound from the external environment. It may be described as a ringing, hissing, buzzing, sizzling, whistling, or humming, and can be constant or intermittent, and unilateral or bilateral. Tinnitus is classified as:
Subjective tinnitus (more common) if the perceived sound can only be heard by the affected individual. This is caused by abnormal activity in the inner ear or central nervous system.
Objective tinnitus (affecting 1% of people with tinnitus) if the sound can be heard by the affected individual and the examiner. This often originates from an identifiable and correctable source that produces sound near to, or within, the ear (for example a vascular abnormality producing a pulsatile sound near to the ear, or muscle-related noise).
Tinnitus is a relatively common symptom. The British Tinnitus Association (BTA) revealed in early 2019 that it was updating its estimate of the number of people who are living with persistent tinnitus in the UK from 1 in 10 people (10% of the population) to 1 in 8 (13.2%). Numerous studies tell us that tinnitus is one of the most common physical symptoms experienced by humans. If this is the case we must ask ourselves, why is it so common?
A number of risk factors have been associated with tinnitus. It is well documented that it tends to increase with age and is also more prevalent in women than men, a fact interestingly supported with the latest research coming out of Cambridge. Unsurprisingly, noise and hearing loss also play their part. General health has been proposed as a risk factor with observations that hypertension and cardiovascular disease can reduce cochlear function and thus generate tinnitus. And interestingly studies have shown tinnitus to be most common in both ears but thereafter showing a dominance in the left ear. Despite this, it’s origin is still unknown.
And whilst most research focuses on tinnitus in adults, let’s not forget that children complain of tinnitus too. It is often thought that tinnitus in children is rare or non-existent, but it is quite the opposite with prevalence figures very similar to adults. Far less common however are children seeking help for tinnitus.
So with so many people "suffering" with tinnitus, why haven't we found a cure? Research conducted by the Australian Tinnitus Society tried to find out what treatments patients wanted. This might seem obvious but the question needed to be answered in an effort to determine why a cure was still not on the horizon. The study showed that an effective drug was the treatment patients most desired. And in most cases, patients would be willing to pay upwards of A$1000 for a treatment if they were assured there would be a reduction or more hopefully, a complete elimination of the tinnitus.
If this is the case, then why are drug companies not developing such a medication. It sounds like it could be lucrative? Well, one of the main stumbling blocks is that we have no objective way of determining whether someone has tinnitus, how severe the tinnitus is and whether treatments improve tinnitus. In addition, some studies dating back to 1984 show that the placebo effect can have as much of a positive effect on tinnitus as some drug treatments used in clinical trials.
Let's also bear in mind that most patients are told at primary healthcare levels that there is no cure for tinnitus so it is also difficult to know how many people are actually "suffering" with tinnitus as they never progress in the system. We cannot forget those who never seek a primary care opinion in the first place for this same reason. Given there is no objective way of determining the severity of tinnitus and no objective way of measuring whether treatments improve tinnitus, how do we assess the impact of an intervention. In healthcare, there are a number of biomarkers for different health conditions, ie cholestrol is a well known biomarker of risk for coronary heart disease. We don't have a biomarker for tinnitus. While we may be waiting patiently for a cure, there are many reasons to explain why this is taking as long as it is.
So what can we do now?
Looking ahead, what can we expect in the absence of a pharmacological solution? Well, there is plenty of research ongoing which should reassure you that as a tinnitus sufferer, you are not forgotten. A recent paper published in the 'Journal of Psychology Research and Behaviour Management' showed very positive results. The study looked at the success of cognitive behavioural therapy (CBT) in alleviating the distress of tinnitus. The results showed that whilst CBT didn't reduce the loudness of the tinnitus, 65% of patients in the study reported a 5/5 score for effectively reducing the distress the tinnitus caused. Furthermore, CBT was just as successful when delivered in group settings as it was in 1-1 settings and was also effective when delivered via the internet with the support of an audiologist. I was really impressed with these results.
Another study published in 'American Journal of Audiology' looked at the level of the stress hormone cortisol in patients saliva on waking each morning. The purpose of the study was to see if these levels might be an effective measure of tinnitus distress. Waking up is the time of day when you are secreting the highest levels of cortisol in anticipation of the day ahead. It is understood already that too much cortisol in the morning is a sign of stress and too little is a sign of burnout. Having high levels in the morning has been linked to disorders such as anorexia and obsessive compulsive disorder. Low levels are more linked to depression and chronic fatigue. Research suggests patients with distressing tinnitus have little cortisol upon wakening. This means they have no control, an inability to relax and emotional distress caused by the tinnitus so their bodies have shut down cortisol production. So whilst the study aim was to look at measuring tinnitus distress, it also reminds us that anything you can do to reduce your levels of stress will assist in resetting your cortisol levels so that the production is within normal limits. Exceptionally difficult to do currently when the stresses of home-schooling, work, working from home, financial worries, lack of social contact, social isolation.....the list goes on, make it really hard not to stress.
Whilst there is no cure, there are many things you can do to help reduce your perception and indeed your distress of tinnitus. Again, these things are all incredibly difficult to follow when our lives have been so unimaginably disrupted by the Coronavirus pandemic. However, given a pharmacological solution is not going to present itself anytime soon it should be reassuring to know that research is still ongoing and different interventions, some conservative and some invasive are producing some very positive results.
In the meantime, treat your tinnitus as holistically as possible. Look at anything you can do that triggers a sense of happiness and well-being. Look into CBT which is showing exceptionally good results or sound relaxation. In addition, mindfulness or hypnotherapy. There is no one solution, and what may work for one, may not work for another. Above all, do not look for a cure. There isn't one. Look to improve your overall life and in the process you may find improvements to be had on your tinnitus.
Some useful resources:
www.tinnitus.org.uk British Tinnitus Association (BTA)
www.rnid.org.uk Royal National Institute for the Deaf (formerly Action on Hearing Loss)